Management of Pain in the Older Person With Cancer Part 1: Pathophysiology, Pharmacokinetics, and Assessment
Your Older Patient
By Marvin Omar Delgado-Guay, MD1, Eduardo Bruera, MD2 |
January 1, 2008
2Professor and Chair, Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
Comprehensive Assessment of Pain in Older Cancer Patients
The elderly need an individualized approach to pain assessment that should take into account not only tumor histology and stage, but also the patient's medical, psychosocial, and spiritual conditions. Appropriate multidimensional geriatric assessment[2,29] should include the medical history and tumor staging, physical examination, performance status (Karnofsky Performance Scale or Eastern Cooperative Oncologic Group Scale),[30-33] Activities of Daily Living (according to the 6-item ADL scale of Katz et al or the 8-item instrumental ADL scale of Lawton et al), the physical performance test, evaluation of comorbid conditions,[37,38] affective status (especially the presence of depression and/or anxiety), cognitive status (using the Mini-Mental State Examination [MMSE]), and evaluation for geriatric syndromes such as dementia, delirium, failure to thrive, neglect or abuse, falls, and incontinence. Table 1 shows a multidimensional approach to older cancer patients with pain.
One of the greatest barriers to cancer pain assessment in elderly patients is delirium. Defined as a transient and potentially reversible disorder of cognition and attention, delirium frequently complicates care at the end of life. In general, the etiology of delirium is multifactorial, especially in patients with advanced cancer and the elderly.[1,42-46] Delirium causes significant distress; it impedes communication with family members and caregivers at a time when it is often most desired.[44,45]
Common Behavioral Expressions of Pain in Older Cancer Patients With Cognitive Impairment
Prompt recognition of delirium is important not only because delirium can make the reliable reporting of symptoms difficult for patients, who frequently present with disinhibition,[44,45] and renders them unable to participate in decisions about therapeutic interventions, but because patients may benefit from appropriate interventions such as supportive psychotherapy. Some pain behaviors in older patients with cognitive impairment can help the identification of distress in these patients; Figure 2 summarizes these behaviors.
If delirium is not recognized, not only family members but also health-care providers may misinterpret agitation as a sign of pain, resulting in escalated doses of opioids that can produce toxicity and complicate the delirium. To facilitate the diagnosis of delirium and impose relatively little burden on patients, instruments with adequate psychometric properties have been created, such as the Memorial Delirium Assessment Scale (MDAS),[1,41-43] the MMSE, and the Confusion Assessment Method (CAM).
The MDAS, a validated tool used in our palliative care practice, was designed to measure the severity of delirium and therefore captures behavioral manifestations as well as cognitive deficits. This instrument measures relative impairment in awareness, orientation, short-term memory, digit span, attention capacity, organizational thinking, psychomotor activity, and sleep-wake cycle, as well as perceptual disturbances and delusions. Items are rated from 0 (none) to 3 (severe), depending on the level of impairment, with a maximum possible score of 30. The higher the score, the more severe the delirium. A total MDAS score of 7 out of 30 yields the highest sensitivity (98%) and specificity (96%) for the diagnosis of delirium.
It is important to mention that frail elderly cancer patients with baseline cognitive impairment or with dementia may develop delirium secondary to the presence of pain, thus appropriate evaluation of the possible sources of pain, such as fractures, constipation, bowel obstruction, and/or urinary retention, must be performed, and therapy should be oriented to treat the underlying cause and other symptoms accompanying the delirium.
Cognitive decline can be a barrier to proper pain assessment, although reliable pain measurements can still be obtained from persons with mild or moderate cognitive impairment.[8,47] Pautex et al showed that 61% of 129 severely demented patients (mean age = 83.7 years) were able to demonstrate comprehension of at least one of the three self-assessment tools for pain evaluation (verbal, horizontal visual, and faces pain scales). A better comprehension rate was noted for the verbal and faces pain scales than for the horizontal visual scale. In addition, the investigators suggested that the observational rating scale may underestimate the severity of pain when compared with self-assessment scales.
As a part of the history taken for an older cancer patient with pain, it is important to ask for the characteristics and intensity of pain and about any variation in pain with change of movement or time of day, and how the pain affects the patient's Activities of Daily Living.[7,8]
The Edmonton Symptom Assessment Scale (ESAS) is an important tool for evaluating symptoms that an older cancer patient has experienced over the past 24 hours.[49-51] This scale assesses nine common symptoms (pain, fatigue, nausea, depression, anxiety, drowsiness, shortness of breath, appetite, and sleep problems) and feeling of well-being. The patient rates the intensity of each symptom on a 0 to 10 numerical scale, with 0 representing "no symptom" and 10 representing the "worst possible symptom." The ESAS, which is free and available in English and 14 other languages, has been found to be reliable in cancer patients and to have internal consistency, criterion validity, and concurrent validity. Its ease of use and visual representation make it an effective and practical bedside tool that allows the health-care provider to track symptoms over time with regard to intensity, duration, and responsiveness to therapy. The symptoms identified in the ESAS help us to better understand the factors related to the expression of pain.
Another important tool to use in older cancer patients with pain is the CAGE questionnaire,[53,54] which screens for alcohol(Drug information on alcohol) abuse at any period of life. This simple tool consists of four questions: Have you ever felt that you should Cut down on your drinking? Have you been Annoyed by people criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink to get rid of a hangover, ie, an Eye-opener?
An abnormal score, defined as two or more positive answers to the four questions, has been shown to have prognostic value in opioid management in patients with cancer who experience pain. The CAGE questionnaire help us to identify patients who are at high risk of developing chemical coping and subsequently high risk of opioid dose escalation and overall increased risk of opioid-induced toxicity. Approximately 20% of cancer patients have a positive CAGE questionnaire.[53,54]
Financial Disclosure: The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.
Management of Pain in the Older Person With Cancer
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